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Cancer, testicular

Cancer of the testicles, also known as testicular cancer, is an uncommon type of cancer that primarily affects younger men.

The most common symptom of testicular cancer is a painless lump or swelling in the testicles.

The testicles

The testicles are the two oval-shaped male sex organs that sit inside the scrotum on either side of the penis. The testicles are an important part of the male reproductive system because they produce sperm and the hormone testosterone, which plays a major role in male sexual development.

Types of testicular cancer

The different types of testicular cancer are classified by what type of cells the cancer first begins in.

The most common type of testicular cancer is known as 'germ cell testicular cancer', which accounts for around 95% of all cases. Germ cells are a type of cell that the body uses to help create sperm.

There are two main subtypes of germ cell testicular cancer. They are:

seminomas, which account for 40% of all cases of testicular cancer

non-seminomas, which account for the remaining 60% of cases of testicular cancer

In practical terms, the only important difference between the two subtypes is that seminomas tend to respond better to radiotherapy (treatment that uses radiation to kill cancer cells) and non-seminomas tend to respond better to chemotherapy (treatment that uses medication to kill cancer cells).

Less common types of testicular cancer include:

Leydig cell tumours, which account for around 1-3% of cases

Sertoli cell tumours, which account for around 1% of cases

This article focuses on germ cell testicular cancer. The Macmillan website has more information about Leydig cell tumour and Sertoli cell tumour.

How common is testicular cancer?

Testicular cancer is relatively uncommon, accounting for just 1% of all cancers that occur in men. Each year in Ireland, it is estimated that there are about 165 new cases diagnosed.

Testicular cancer is unusual compared to other types of cancers because it tends to affect younger men who are 20 to 55 years of age. As a result, although relatively uncommon overall, testicular cancer is the most common type of cancer to affect young men (20 to 35 years of age).

Rates of testicular cancer are five times higher in white men than in black men. The reasons for this are unclear.

The number of cases of testicular cancer that are diagnosed each year has roughly doubled over the last two decades in European and North American nations. On the other hand, testicular cancer is virtually unheard of in some African and Asian nations. Again, the reasons for this are unclear.

The cause or causes of testicular cancer are unknown, but a number of risk factors have been identified that increase the chance of developing the condition. These include:

having a family history of testicular cancer

being infertile

being born with undescended testicles (cryptorchidism). About 3-5% of boys are born with their testicles located inside their abdomen, which usually descend into the scrotum during the first four months of life

Outlook

The outlook for testicular cancer is very good because it is one of the most treatable types of cancer. Over 95% of men with early stage testicular cancer will be completely cured.

Even cases of advanced testicular cancer, where the cancer has spread outside the testicles to nearby tissue, have an 80% chance of being cured.

Compared to other cancers, deaths from testicular cancer are rare. For example, in 2007, only 5 deaths were caused by testicular cancer in Ireland.

Treatment for testicular cancer includes the surgical removal of the affected testicle (which should not affect fertility or the ability to have sex), chemotherapy and radiotherapy.

Benign

The term benign refers to a condition that should not become life threatening. In relation to tumours, benign means not cancerous.

Malignant

Malignant is a term used to describe a life threatening or worsening condition. In the case of tumours, malignant means cancerous.

Testicles

Testicles are the two oval-shaped reproductive organs that make up part of the male genitals. They produce sperm and sex hormones.

Testosterone

Testosterone is a male sex hormone that is involved in making sperm and sexual characteristics, such as the development of a deeper voice. Testosterone is also found in small amounts in women.

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The most common symptom of testicular cancer is a lump or swelling in one of your testicles.

Testicular lumps are most commonly found on the front or the side of the testicle. They often feel like a hard, pea-sized swelling.

When to see your GP

Never ignore a lump or a swelling in your testicle. It is very important to visit your GP as soon as you notice any lump or swelling on your testicle.

Your GP will examine your testicles to help determine whether or not the lump is cancerous. Most testicular lumps are not a sign of cancer. For example, varicoceles (swollen blood vessels) are a common cause of testicular lumps.

For more information about varicoceles, see the Health A-Z topic about Testicular lumps and swellings.

Research has shown that less than 4% of testicular lumps are cancerous. In the unlikely event that you do have testicular cancer, the sooner treatment begins, the greater the likelihood that you will be completely cured.

Metastatic cancer

If testicular cancer has spread to other parts of your body, you may also experience a variety of other symptoms. Cancer that has spread to other parts of the body is known as metastatic cancer. Around 5% of people with testicular cancer will experience symptoms of metastatic cancer.

The most common place for testicular cancer to spread is to nearby lymph nodes in your abdomen or your lungs. Lymph nodes are glands that make up your immune system. Less commonly, the cancer can spread to your liver, brain or bones.

Symptoms of metastatic cancer can include:

a persistent cough

coughing or spitting up blood

shortness of breath

swelling and enlargement of male breasts

a lump or swelling in your neck

lower back pain

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Cancer

Cancer begins with an alteration to the structure of the DNA that is found in all human cells. This is known as a genetic mutation. The DNA provides the cells with a basic set of instructions, such as when to grow and reproduce.

The mutation in the DNA changes these instructions so that the cells carry on growing. This causes the cells to reproduce uncontrollably, producing a lump of tissue known as a tumour.

How cancer spreads

Most cancers grow and spread to other parts of the body through the lymphatic system. The lymphatic system is a series of glands (or nodes) that are located throughout your body in a similar way to the blood circulation system. The lymph glands produce many of the specialised cells that are needed by your immune system (the body's natural defence against disease and infection).

Left untreated, testicular cancer will first spread into nearby blood vessels and lymph nodes. Over time, the cancer can spread through the lymphatic system into other parts of the body, such as the lungs, liver, bones and brain.

Risk factors

It is not known what triggers the onset of testicular cancer. However, research has identified a number of factors which may increase your chances of developing the condition. Two of these risk factors are outlined below.

Undescended testicles

The medical name for undescended testicles is cryptorchidism. When male babies grow in the womb, their testicles develop inside their abdomen. The testicles then normally move down into the scrotum when the baby is born or during their first year of life.

However, for some children, the testicles fail to descend into the scrotum. Surgery is usually required to move the testicles down. If you have had surgery to move your testicles down into your scrotum, your risk of developing testicular cancer may be increased.

One study found that if surgery is performed before the child is 13 years of age, their risk of later developing testicular cancer is approximately double that of the rest of the population. However, if the operation is carried out after the boy is 13 years of age, the risk of developing testicular cancer is five times greater than that of the rest of the population.

Age and race

Unlike most other types of cancer, testicular cancer is more common in young and middle-aged men than in older or elderly men. It most commonly affects men between 20 and 44 years of age, with 90% of testicular cancer cases affecting men under the age of age 55.

Testicular cancer is more common in white men than other ethnic groups. It is also more common in northern and western Europe compared with other parts of the world.

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Visiting your GP

See your GP if you notice a lump or abnormality on or in your testicles. Most testicular lumps are not cancerous, but it is essential that you have the abnormality checked. This is because the treatment for testicular cancer is much more effective when it is started as soon as possible after the condition is diagnosed.

Physical examination

As well as asking you about your symptoms and consulting your medical history, your GP will usually need to carry out a physical examination of your testicles.

Your GP may hold a small light or torch against the lump in your testicle to see whether light passes through it. Cancerous lumps tend to be solid, which means that light is unable to pass through them.

If your GP suspects that the lump in your testicle may be cancerous, you will be referred for further testing at a hospital. Some of the tests that you may have are outlined below.

Scrotal ultrasound

A scrotal ultrasound scan is a painless procedure that uses high-frequency sound waves to produce an image of the inside of your testicle. This is one of the main ways that your radiologist (a doctor who specialises in using imaging equipment such as ultrasound scans) will be able to determine whether or not your lump is cancerous.

During a scrotal ultrasound, your specialist will be able to determine the position and size of the abnormality in your testicle.

It will also give them a clear indication of whether the lump is solid or whether it is filled with fluid. A lump that is filled with fluid is known as a cyst and is usually harmless. A more solid lump may be a sign that the swelling is cancerous.

Blood tests

To help confirm your diagnosis, you may require a series of blood tests. These tests will be used to detect certain hormones in your blood, which are known as 'markers'. Testicular cancer often produces these markers, so having them in your blood may be a strong indication that you have the condition.

The markers in your blood that will be tested for include:

AFP (alpha feta protein)

HCG (human chorionic gonadotrophin)

LDH (lactate dehydrogenate)

Not all forms of testicular cancer produce these markers. There may still be a chance that you have testicular cancer even if your blood test results come back normal.

Biopsy

The only way to definitively confirm a case of testicular cancer is to have a biopsy of the tumour taken. The cells from the tumour can be examined in a laboratory to determine whether it is cancerous (malignant) or non-cancerous (benign).

A biopsy usually involves taking a small sample of cells from the tumour. For most cases of testicular cancer, the only way to safely take a biopsy is to remove the affected testicle completely. Most solid lumps in the testis are cancer.Biopsy through the skin can lead to contamination of that area with cancer cells, so removal of the testicle is considered the safest option. An artificial prosthesis can be placed in the scrotum instead,and this should be discussed with every patient before surgery.

Your specialist will only recommend removing your testicle if they are relatively certain that your lump is cancerous. Losing a testicle will not affect your sex life or your ability to have children.

The removal of a testicle is known as an orchidectomy. The main form of treatment for testicular cancer is removing the affected testicle, so if you have testicular cancer it is likely that you will need to have an orchidectomy at some point.

Other tests

If your specialist feels it is necessary, you may require further tests to check whether testicular cancer has spread to any other parts of your body. When cancer of the testicle spreads, it most commonly affects the lungs.

Staging

Once the above tests have been completed, it is usually possible to determine the stage of your cancer, as well as any resulting implications, both in terms of your treatment and the possibility of achieving a complete cure.

There are two ways that the staging of testicular cancer can be categorised. The first is known as the TMN staging system:

T indicates the size of the tumour.

N indicates whether the cancer has spread to nearby lymph nodes.

M indicates whether the cancer has spread to other parts of the body (metastasis).

While widely used, the TNM system can sometimes be difficult for someone with little or no medical expertise to understand. Therefore, for the sake of clarity, the rest of the article will use the second staging system, where the stages of testicular cancer are described numerically.

In the numerical system, there are four main stages:

Stage 1: the cancer is contained inside your testicles.

Stage 2: the cancer has spread from the testicles into the lymph nodes in your abdomen and pelvis.

Stage 3: the cancer has spread into the lymph nodes in your upper chest.

Stage 4: the cancer has spread into another organ, such as your lungs.

Benign

Benign refers to a condition that should not become life threatening. In relation to tumours, benign means not cancerous.

Biopsy

A biopsy is a test that involves taking a small sample of tissue from the body so it can be examined.

Incision

An incision is a cut made in the body with a surgical instrument during an operation.

Lungs

Lungs are a pair of organs in the chest that control breathing. They remove carbon dioxide from the blood and replace it with oxygen.

Lymph nodes

Lymph nodes are small oval tissues that remove unwanted bacteria and particles from the body. They are part of the immune system.

Testicle

Testicles are the two oval-shaped reproductive organs that make up part of the male genitals. They produce sperm and sex hormones.

X-ray

An X-ray is a painless way of producing pictures of inside the body using radiation.

The first treatment option for all cases of testicular cancer, whatever the stage, is to surgically remove the affected testicle (an orchidectomy).

In cases of stage one seminomas and non-seminomas , the management is either surveillance or a short course of chemotherapy.

In stage two or three the treatment is removal of the testis first ,then chemotherapy.

In stage three cancer, surgery will be required to remove the affected lymph nodes. Three to four cycles of chemotherapy will then be given using a combination of different medications.

A similar treatment plan is used to treat stage four cancer. Additional surgery may also be required to remove tumours from other parts of the body, such as the lungs.

Deciding what treatment is best for you can be difficult. Your cancer team will make recommendations, but the final decision will be yours.Your sperm should be banked before chemotherapy.

Before going to hospital to discuss your treatment options, you may find it useful to write a list of questions to ask the specialist. For example, you may want to find out what the advantages and disadvantages of particular treatments are.

Orchidectomy

An orchidectomy is the medical name for the surgical removal of a testicle. If you have testicular cancer, it is necessary to remove the whole testicle because only removing the tumour may lead to the cancer spreading. By removing the entire testicle, your chances of making a full recovery are greatly improved.

If you have testicular cancer that is detected in its very early stages, an orchidectomy may be the only treatment you require.

The operation is performed under general anaesthetic. A small incision (cut) is made in your groin and the whole testicle is removed through the incision. If you want, you can have an artificial (prosthetic) testicle inserted into your scrotum so that the appearance of your testicles is not greatly affected. The artificial testicle is usually made from silicone (a soft type of plastic).

After an orchidectomy, you will need to stay in hospital for a few days. If you only have one testicle removed, there should not be any lasting side effects. Your sex life and your ability to father children will not be affected.

If you have both testicles removed (a bi-lateral orchidectomy), you may not be able to father children through intercourse,but you can have children through artificial means. However, it is only necessary to remove both testicles in 1 in every 100 cases and your sperm will be banked before having a bi-lateral orchidectomy to allow you to father children if you decide to.

Testosterone replacement therapy

Having both testicles removed will also stop you from producing testosterone. This means that you will have a low libido (a decreased sex drive) and you will not be able to get or maintain an erection. In this case, you will require testosterone replacement therapy.

Testosterone replacement therapy is where you are given a synthetic version of the testosterone hormone to compensate for the fact that your testicles will no longer produce a natural version of the hormone.

Testosterone is usually given either as injections or skin patches. If you have injections, you will usually need to have them every two to three weeks. If you have testosterone replacement therapy, you will be able to maintain an erection and your sex drive.

Side effects of testosterone replacement therapy are uncommon and are usually mild. They include:

a change in your normal urinary patterns, such as needing to urinate more frequently or having problems passing urine (caused by an enlarged prostate gland which puts pressure on your bladder)

Lymph node surgery

If your testicular cancer is more advanced, it may spread to your lymph nodes. Your lymph nodes are part of your body's immune system, which help to protects it against illness and infection.

Lymph node surgery is carried out under general anaesthetic. The lymph nodes in your chest and abdomen are the most likely nodes that will need to be removed.

In some cases, the nerves that are near to the lymph nodes can become damaged, which means that you will not be able to ejaculate semen.

As with an orchidectomy, you may wish to bank your sperm before your operation, in case you become infertile.

Nerve-sparing retroperitoneal lymph node dissection

A new type of lymph node surgery, called nerve sparing retroperitoneal lymph node dissection (RPLND), is increasingly being used because it carries a lower risk of affecting your ability to ejaculate.

In nerve-sparing RPLND, the site of the operation is limited to a much smaller area. The advantage of limiting the site of the operation is that there is less chance of nerve damage occurring. The disadvantage is that by limiting the site of the operation, the surgery is much more technically demanding. For this reason it is performed only by surgeons with the required training.

For men who have a residual mass after chemotherapy ,or in rare cases for men who refuse or are not suitable for chemotherapy, RPNLD( nerve sparing) is now the gold standard treatment and should be offered to them.

Radiotherapy

Radiotherapy is a form of cancer therapy that uses high-energy beams of radiation to help destroy cancer cells Seminoma types of testicular cancer may benefit from radiotherapy as well as surgery. This is to help prevent the cancer from returning.

If your testicular cancer has spread to your lymph nodes, you may also require radiotherapy.

The side effects of radiotherapy can include:

reddening and soreness of the skin, which is similar to sunburn

nausea

diarrhoea

fatigue

These side effects are usually only temporary and should improve after you have completed your treatment.

Chemotherapy

Chemotherapy is a type of cancer treatment that uses anti-cancer medicines to kill the malignant (cancerous) cells in your body or stop them from multiplying.

If you have advanced testicular cancer or it has spread to other places in your body, you may require chemotherapy. It is also used to help prevent the cancer returning. Chemotherapy is most commonly used to treat non-seminoma tumours.

Chemotherapy medicines are usually injected or given orally (by mouth). Sometimes, chemotherapy medicines can attack your body's normal, healthy cells. This is why chemotherapy can have many different side effects. The most common side effects of chemotherapy include:

vomiting

hair loss

nausea

sore mouth

loss of appetite

fatigue

breathlessness

infertility (usually temporary)

ringing in your ears (tinnitus)

skin that bleeds or bruises easily

increased vulnerability to infection

numbness and tingling (pins and needles) in your hands and feet

These side effects are usually only temporary and should improve after you have completed your treatment.

You should not father children while you are receiving chemotherapy and for a year after treatment has finished. Chemotherapy medications can temporarily damage your sperm, increasing your risk of fathering a baby with serious birth defects. Therefore, you will need to use a reliable method of contraception, such as a condom, during this time.

Sperm should always be banked before chemotherapy is commenced.

Condoms should also be used during the first 48 hours after having a course of chemotherapy. This is to protect your partner from any potential harmful effects of the chemotherapy medication in your sperm.

Follow-up

Even if your cancer has been completely cured, there is a risk that it will later return. Around 25-30% of people will experience a return of the cancer, usually within the first two years after their treatment has finished.

Due to this risk, you will require regular tests to check whether the cancer has returned. These tests include:

a physical examination

blood tests

chest X-ray

computerised tomography (CT) scan

Testing is usually recommended every three months during the first year after treatment. After the first year, the tests will be less frequent, decreasing to twice a year, and then annually.

If the cancer does return and is diagnosed at an early stage, it will usually be possible to cure it using radiotherapy and chemotherapy. Some types of recurring testicular cancer have a cure rate of almost 100%.

Chemotherapy

Chemotherapy is a treatment of an illness or disease with a chemical substance, such as in the treatment of cancer.

Hormone replacement therapy

Hormone replacement therapy or HRT involves giving hormones to women when the menopause starts, to replace those that the body no longer produces.

Lymph nodes

Lymph nodes are small oval tissues that remove unwanted bacteria and particles from the body. They are part of the immune system.

Radiotherapy

Radiation therapy uses X-rays to treat disease, especially cancer.

Testicle

Testicles are the two oval-shaped reproductive organs that make up part of the male genitals. They produce sperm and sex hormones.

Testosterone

Testosterone is a male sex hormone, which is involved in making sperm and sexual characteristics such as the voice getting deeper. Testosterone is also found in small amounts in women.

Testicular cancer cannot usually be prevented, so it is important to check your testicles regularly. Cancer is easier to treat when it is diagnosed early on. If you regularly examine your testicles, you are likely to notice any swelling or abnormalities when they are at an early stage of development.

Checking your testicles

The best time to check your testicles is after a warm shower or bath because this is when your scrotal skin will be most relaxed.

Hold your scrotum in the palms of your hands, and use your fingers and thumbs to examine your testicles. You should first feel the size and weight of your testicles. A lot of men have one testicle which is larger than the other. You may also have one testicle that hangs slightly lower than the other.

If you notice any significant increase in the size or weight of your testicles, it could be a sign that something is wrong. See your GP for advice.

As well as feeling the size and weight of your testicles, gently feel each testicle individually.

When you examine your testicles, they should feel smooth with no lumps or swellings. You should be able to feel a soft, tube-like section at the top and back of each testicle. This is your epididymis, which is used to store sperm. It may feel slightly tender, which is perfectly normal.

It is very rare to develop cancer in both testicles. Therefore, if you are unsure about what your testicle should feel like, try comparing it to your other one.

If you find a lump or a swelling while checking your testicles, visit your GP as soon as possible.

Smoking

Of all of the known risk factors for testicular cancer, smoking is the one risk factor you can address. If you smoke, giving up will half your risk of developing testicular cancer, as well as reducing your risk of getting many other serious health conditions, such as lung cancer and heart disease.

If you decide to stop smoking, your GP will be able to refer you to your local smoking cessation service which will give you dedicated help and advice about the best ways to give up.

You can also call the National Smokers Quitline at 1850 201 203, or log on to www.quit.ie, or the HSE facebook page at www.facebook.com/hsequit.

If you are committed to giving up smoking but do not want to be referred to a stop smoking service, your GP should be able to prescribe medical treatment to help with any withdrawal symptoms you may have after quitting.

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Routine checks

There is disagreement among the international medical community about who should check for testicular cancer and how often.

The American Cancer Society (ACS) recommends that regular checks are only required in men with pre-existing risk factors such as:

a family history of testicular cancer

a history of undescended testicles

being infertile

ACS argues that there is no evidence that regular self-examinations help to lower the number of testicular cancer deaths, but that it may be causing unnecessary anxiety and worry in men who have non-cancerous lumps (around 96% of all cases of lumps or swellings in the testicles).

Organisations such as the Department of Health in the UK (DH) and Cancer Research UK recommend that all men should check their testicles regularly (usually once a month).

They argue that even though the vast majority of cases of testicular lumps are not caused by cancer, routine self-examination is justified by the fact that the earlier testicular cancer is diagnosed, the greater the chance of it being cured.